In developing countries, typhoid fever is common, serious, and increasingly difficult to treat because of resistance of the bacillus to antibiotics. [24, 63-66]. For example, more than 80% of Salmonella typhi from the Mekong Delta region of Vietnam are resistant to chloramphenicol and to ampicillin and even more expensive antibiotics such as ciprofloxacin. Typhoid fever has been thought of as a disease of mostly older children and young adults. In children less than 5 years of age, typhoid fever was often unrecognized due to atypical clinical symptoms, difficulties in drawing blood and less-than-optimal culture media. [66-69]. Similar to recent findings in other parts of Southeast Asia [70-72], a preliminary survey in 3 communes of the Dong Thap province of Vietnam showed that the annual attack rate of typhoid fever was highest among children less than 15 years of age: it was 413/100,000 in this age group and 358/100,000 for 2 to 4 year-olds. [73].
Unfortunately, it is unlikely that safe drinking water and foodstuffs will be available in many developing countries, especially in rural areas, in the near future. [24, 66, 74]. Control of typhoid fever by routine vaccination, especially in countries that endure high endemic rates of typhoid fever, has not been adopted because of the limitations of the three licensed vaccines (parenteral inactivated cellular vaccines, oral attenuated S. typhi Ty21a, and parenteral Vi polysaccharide). These vaccines confer only approximately 70% immunity to older children and adults but do not protect young children. [24, 1, 30, 75, 76].
Orally administered attenuated S. typhi Ty21a requires at least 3 doses, has a low rate of efficacy in areas with a high rate of typhoid fever and in travelers from developed countries and is not immunogenic in young children. Neither the protective antigens nor the vaccine-induced host immune responses have been identified which hinders improvement of the Ty21a vaccine.
Although effective in areas with high rates of typhoid fever, killed whole cell parenteral vaccines elicit a high rate of adverse reactions and have not been shown to be effective in young children. In 1952, Landy concluded that the protective antigen of cellular vaccines is the capsular polysaccharide (Vi) of S. typhi. 
In two randomized, double-blinded, vaccine-controlled clinical trials, one injection of Vi induced about 70% efficacy in ≧5 year-olds in the Kathmandu Valley of Nepal and in the Eastern Transvaal region of the Republic of South Africa: these regions had a high rate of endemic typhoid (0.4 to 1% per year) [1]. Recently, similar results were obtained by the Lanzhou Institute of Biologic Products in the People's Republic of China [manuscript in preparation]. Vi is easily standardized. The World Health Organization has published requirements for Vi polysaccharide typhoid vaccine and this product is licensed in about 50 countries including the United States [59,60]. But Vi induces only short-lived antibody responses in children two to five years of age and does not elicit protective levels in children less than two years old: in adults, reinjection restores the level of vaccine-induced anti-Vi but does not elicit a booster response. These age-related and T-independent immunologic properties are similar to most other polysaccharide vaccines.
We proposed that it is the vaccine-induced serum IgG anti-Vi that confers immunity. Accordingly, the level of serum IgG anti-Vi should predict the efficacy of Vi vaccine. In order to improve its immunogenicity, Vi was conjugated to proteins using SPDP [51, 52, 54, 62]. The protein carriers for the SPDP linked conjugates included cholera toxin (CT), tetanus toxoid (TT), the B subunit of the heat-labile cholera-like enterotoxin (LT-B) of Escherichia coli and the recombinant exoprotein A (rEPA) of Pseudomonas aeruginosa (i.e., the nontoxic recombinant form of exotoxin from Pseudomonas aeruginosa (ETA) cloned into and secreted by E. coli). [Id.]. Recently, we employed another synthesis that treated rEPA with adipic acid dihydrazide (ADH) and bound the hydrazide derivative of rEPA (rEPA-AH) to Vi with 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) [31]. The safety and immunogenicity of the Vi-rEPA conjugates prepared either with N-succinimidyl-3-(2-pyridyl dithio) propionate (SPDP, Vi-rEPAI) or adipic acid dihydrazide (ADH, Vi-rEPAII) as linkers, were compared sequentially in adults, 5-14 year-olds and then 2-4 year olds in Vietnam. The data set forth in Example 5 herein demonstrate that the resultant conjugate (Vi-rEPA) both enhanced the immunogenicity of and conferred T-cell dependent properties to Vi. Vi-rEPA elicited a booster response in 2 to 4 year-olds with IgG anti-Vi levels approximately 3 times higher than those elicited by Vi in 5 to 14 year-olds. None of the vaccines had a temperature >38.5° C. or swelling >2.5 cm following injection. On the basis of these results, we initiated a double-blinded placebo-controlled randomized trial to determine the efficacy of Vi-rEPA in 2 to 5 year-old Vietnamese children, an age group for which there is yet no effective typhoid vaccine. The results of that efficacy trial are set forth in Example 6 herein.